Improved prediction of metastasis in tongue carcinomas, combining vascular and nuclear tumor parameters

BACKGROUND

Predicting the presence of metastasis, based on tumor or tumor-related characteristics is of utmost importance. The authors studied the significance of tumor DNA features and tumor-related angiogenesis to predict the occurrence of metastasis in squamous cell carcinomas (SCCs) of the tongue.

METHODS

Paraplast blocks from resection specimens of 20 metastasized and 20 nonmetastasized SCCs of the tongue with a minimum follow-up of 24 months were used. Tissue sections were stained with anti-CD34 monoclonal antibodies for vessel visualization, and according to Feulgen to stain DNA. Using image analysis, data from both stainings were computed for each of the 40 carcinomas. A logistic regression model to predict the presence of metastasis, based on vascular and nuclear morphology features, was developed.

RESULTS

The intratumor variation of chromatin condensation and the percentage vessels smaller than 5 microm in diameter were selected for the model. The model correctly predicted metastasis in 90% of patients and excluded metastasis correctly in 75% of nonmetastasized tumors. Taking into account the prevalence of metastasis in SCC of the tongue of between 30% and 60%, this means a predictive value for a negative outcome of between 95% and 83%.

CONCLUSIONS

The proposed model shows an improvement of predictive values compared with previous models with single parameters. Therefore, a multiparameter model appears to predict the multiparameter process of metastasis better.

[Stability of orthodontic-maxillofacial surgical treatment of anterior open bite deformities]]

A sample of 267 patients with maxillary hyperplasia, a Class I or Class II occlusion and anterior open bite, collected from three different institutions, was analysed regarding stability after Le Fort I intrusion osteotomies or bimaxillary osteotomies. Skeletal and dento-alveolar stability of the maxilla, postional changes of the mandible and of incisors were evaluated on cephalometric radiographs. The stability of maxillary arch dimensions after correction of the open bite is measured on dental casts. Patients with anterior open bite, treated with a Le Fort I osteotomy in one-piece or in multi-segments, with or without bilateral sagittal split osteotomy exhibited good skeletal stability of the maxilla. Rigid internal fixation showed better maxillary and mandibular stability than intraosseous wire fixation. Considerable relapse of transverse dimensions, however, was measured after orthodontic and surgical expansion. The mean overbite at the 69 months follow-up was 1.24 mm and lacking of overlap between opposing incisors was present in 19%.

Incorporation of composite bone implants in the facial skeleton

The purpose of this study was to evaluate the capacity of composite grafts consisting of either particulated cancellous or particulated cortical bone and anorganic bovine bone mineral (BBM) (Bio-Oss) to induce regeneration in standardized critical size bony defects overlying the frontal sinus. Four full thickness critical size bone defects were made in the frontal bone in each of 8 skeletally mature female goats. These defects were filled at random with composite cancellous bone/BBM grafts or composite cortical bone/BBM grafts. Control defects were not included but could be evaluated using data from a previous study in which the same experimental setting was used (Merkx et al. 1999a). Fluorochrome bone markers were injected subcutaneously 1 and 5 weeks after implantation, and 1 week before the animals were killed. Two animals were killed at 3, 6, 12 and 24 weeks after surgery respectively. The results were evaluated by histological means including fluorescence microscopy. In conclusion, composite grafts consisting of autogenous cancellous bone/BBM yield good results, combining the advantages of each material alone and reducing the disadvantages of each when used separately. Critical size defects in the maxillofacial area, overlying a paranasal sinus, filled with this material heal uneventfully within 12 weeks. Composite grafts consisting of cortical bone and BBM show less favorable results. These grafts induce osteoclasts, probably by the presence of non-functional BBM, resulting in resorption of the cortical bone chips.

[Needs for implant therapy in cancer patients; a retrospective study]

After cancer treatment in the head and neck area, mastication and speech are often affected. Some of the problems encountered can be solved by adequate dental rehabilitation. However, dental rehabilitation is often compromised, for various reasons. The change in anatomy due to surgery often results in lack of denture bearing mucosa. The effects of radiotherapy of the salivary glands and the mucosa result in dry oral tissues and diminished retention of removable dentures. Osseointegrated implants can help to solve these problems. Implant treatment has, so far, not been widely used in cancer patients. An analysis was made of 95 consecutive patients with a tumor in the head and neck area. The indication for treatment with osseointegrated implants was reviewed and the need for implants as experienced bij patients was evaluated. Results show that 45% did not need specific prosthetic rehabilitation, and approximately 25% of the patients could benefit from osseointegrated implants. Due to general and local contra-indications and patients' refusal, only 3% actually have been treated. For complete oral rehabilitation of this group of patients the use of osseointegrated implants should be considered at an early stage, before the initial tumor treatment.

Psychologic implications of surgical-orthodontic treatment in patients with anterior open bite

Two hundred eighty-two patients who received surgical-orthodontic treatment to correct anterior open bite were retrospectively evaluated by interview and questionnaires to determine the motivation and expectations before treatment, experience during treatment, psychosocial impact, functional and esthetic results, and satisfaction. All patients underwent a Le Fort I osteotomy, and 126 patients also received a bilateral sagittal split advancement osteotomy. The mean follow-up was 6 years. The most important reasons for treatment, as cited by the patients, were biting and chewing problems (28%), dissatisfaction with facial appearance (26%), and symptoms of temporomandibular joint (TMJ) dysfunction (21%). Patients with anterior open bite had a critical attitude toward facial appearance; therefore, esthetic aspects should be taken seriously. The expectations on chewing ability, phonetics, nasal passage, and facial appearance were met by the treatment; however, expectations on TMJ function, interincisal relationship, and biting ability were not completely fulfilled. There was a subjective improvement of TMJ sounds in 27% and a worsening in 14% of the patients. Dysesthesia of the infraorbital nerve was noticed in 4% of patients and of the mental or inferior alveolar nerve in 23% of the patients. Chewing and biting abilities improved in 53% and 73%, respectively. Facial appearance, self-confidence, and social interaction had improved. Patients had expected more information before and psychologic support after treatment. Despite the relapse of open bite in 20% of the patients, 75% were satisfied with the dental and 85% with the facial appearance.

Incorporation of particulated bone implants in the facial skeleton

The purpose of this study was to compare the regenerative response of autogenous cortical and cancellous bone chips and a natural particulate resorbable bone mineral (RBM) (Bio-Oss, Geistlich-Pharma, Wolhusen, Switzerland) in standardized bony defects relating paranasal sinuses to one another and to bone blocks. On 13 skeletally mature female goats four standardized critical-sized full thickness bone defects were made in the frontal bone overlying the frontal sinus. These defects were filled at random with cortical bone chips, cancellous bone chips, spongiosa granules of a RBM or left empty. Fluorochrome bone markers were injected subcutaneously 1 and 5 weeks after transplantation, and one week before the animals were killed. The animals were killed at 3, 6, 12 and 24 weeks after surgery. Autogenous cancellous bone chips is the material of choice for bridging a bony defect in the maxillofacial area where there is no need for mechanical strength. They heal in the same way as cancellous bone blocks do. Cortical bone chips are not reliable enough to be used as a solitary bone-grafting material under these conditions. A cortical block as a solitary implant gives better results. RBM granules as solitary implant in a critical-sized defect do not stimulate osteoconduction but give rise to an extensive osteoclastic activity stimulated by the mutual loose relation. A solid block of RBM is in a similar case more reliable.

Fractures of the frontal sinus: classification and its implications for surgical treatment

PURPOSE

To propose a clinical classification of fractures of the frontal sinus and discuss the implications on treatment.

PATIENTS AND METHODS

One hundred patients with fractures of the frontal sinus seen and operated on in two University hospital units (Leuven and Nijmegen). The majority of the patients were surgically treated according to a protocol based on the proposed classification. Fractures were classified according to their location, extent, involvement of the nasofrontal duct, and injury to the dura. Fragments were reduced and fixed, defects were reconstructed with autologous bone grafts, and the sinus cavity was drained, obliterated, or cranialized. In the latter cases, the sinus mucosa was thoroughly removed before obliteration or cranialization.

RESULTS

The follow-up ranged from 6 months to 12 years. There were functional complications in 4% of patients. Minor aesthetic sequelae were noticed in 14% of the patients.

CONCLUSION

A detailed classification of fractures of the frontal sinus is proposed. It has helped the authors set up a treatment protocol. Optimally, if used by clinicians, it will contribute to a more standardized method of surgical care of patients with such injuries.

[Syndromes 11. Treacher collins syndrome]

Treacher Collins syndrome is seen once in 10.000 births. Inheritance is autosomal dominant with variable expressivity. The most prominent symptoms are antimongoloid slant of the eyelids, hypo- or even aplasia of the zygomata, very hypoplastic mandible with receding chin, deformed ear lobes and conductive hearing loss. With two to three operations a considerable improvement can be achieved. The correction of the eyelids is often the most difficult problem.

Incorporation of three types of bone block implants in the facial skeleton

The regenerative response on autogenous cancellous and cortical bone grafts, and on a commercial available xenogenous resorbable bone mineral (RBM) (Bio-Oss, Geistlich-Pharma, Wolhusen, Switzerland) was compared in standardized bony defects related to a paranasal sinus. On 15 skeletally mature goats four critical sized full thickness bone defects were trephined in the frontal bone. These defects were filled at random with a cortical bone plug, a cancellous bone plug, a plug of spongious RBM cut into shape or left empty. Fluorochrome bone markers were injected subcutaneously 1 and 5 weeks after transplantation, and one week before the animals were killed. The animals were killed at 3, 6, 12 and 24 weeks after surgery. Histological evaluation showed that autogenous bone grafts were all accepted and incorporated in a similar way as in calvarial defects. RBM was only osteoconductive. New bone was formed at the margins of the defects, and only little of the RBM was incorporated. Most of the RBM was gradually resorbed by multinucleated osteoclast-like cells.

[Syndromes 9. Hemifacial microsomia]

Hemifacial microsomia is also known under quite a number of synonyms. Pathognomonic for these usually sporadic cases are: marked three dimensional asymmetry of the mandible, the ear, the maxilla, the zygoma and the orbit. The more distal the structure, the more marked the asymmetry. Many other optional symptoms are described. The differential diagnosis is almost never a problem in this aspecific complex of symptoms. Surgical therapy asks for expert treatment. The treatment contains usually several operations of which one to three are really major. Even then, very good results are mainly obtained in the less pronounced cases only.

[Syndromes 7. Hypertelorism (Greig syndrome)]

Hypertelorism is an increased distance between the orbits. Most evident symptom is the increased intercanthal distance. It can be caused by congenital deformities (facial clefts, encephaloceles, enlarged ethmoïds) and by trauma. Three degrees are differentiated. Grade one and two can be corrected with a small risk for complications. If there is vertical orbital dystopia it has to be corrected by a transcranial procedure, as is necessary in grade 3.

Transalar sphenoidal encephalocele and respiratory distress in a neonate: a case report

We present a full-term newborn infant who suffered from immediate postpartum severe respiratory distress. The infant had an inspiratory stridor as a result of a swelling of the soft palate, extending from the roof of the nasopharynx. Transoral endotracheal intubation resulted in normal saturation levels. Histologic examination after an open biopsy showed mature neuroglial tissue. Radiology demonstrated the presence of a right parapharyngeal process obstructing the nasopharynx and oropharynx and extending to the right middle and posterior fossa, via the foramen ovale. After transoral debulking, the infant was extubated successfully. After an uneventful period of 5 months, the patient was readmitted at our hospital for treatment of meningitis. Subsequently, the inspiratory stridor recurred, and staged surgery was performed. First, a transcranial approach was used to remove a large intradural part of the process and close the defect at Meckel's cave. Two weeks later the retro- and parapharyngeal part of the process were removed transorally. Given the site of the defect of the skull base and the intradural location of the process, the diagnosis is a transalar sphenoidal encephalocele. This is a rare type of basal encephalocele, and has never been reported in an infant nor known to present with respiratory distress. The pathogenesis, clinical presentation, pathology, and therapeutic implications of basal encephaloceles are discussed.

Successful surgical repair of progressive exophthalmos caused by a meningocele in a patient with neurofibromatosis Type 1. Case report

A case of surgical repair of progressive exophthalmos of the right eye in a 43-year-old woman with neurofibromatosis Type 1 (NF1) is presented. Preoperatively, the patient's ocular movements and visual fields were intact. Visual acuity was 20/30 on the right side and 20/20 on the left. Computerized tomography scanning demonstrated complete absence of the superolateral orbital wall on the right side with a large meningocele protruding into the right orbit. Intraoperatively, a new superolateral wall was constructed using the inner table of the left frontal bone as a bone transplant. A free galeoperiosteum flap was used for water-tight dural reconstruction. A few weeks postoperatively the patient's exophthalmos showed remarkable resolution. Her ocular movements, visual acuity, and visual fields remained unchanged. In conclusion, reconstruction of the superolateral wall and repair of a meningocele in a patient with NF1 is worthwhile and can be followed by excellent cosmetic results. More important, the patient's visual functions remain preserved.

[Syndromes 6. Crouzon's disease]

Morbus Crouzon is a syndrome with craniosynostosis. Besides a deviating form of the skull this causes a retropositioned middle third of the face. Therefore pseudo-exophthalmos, strabismus and an Angle Class III relation of the jaws are usually seen. The eyes are especially vulnerable. Since the symptoms are rather symmetrical, a good result of the corrections can usually be achieved. The form of the skull will be corrected in very early childhood, while the deformities of the face are by preference operated after completion of growth. However, different reasons can be found to start correction in an earlier stage.

Open bite deformity in amelogenesis imperfecta. Part 2: Le Fort I osteotomies and treatment results

Functional conditions, skeletal and dento-alveolar stability and condylar changes in 15 patients with mandibular hypoplasia, anterior open bite (AOB) and amelogenesis imperfecta (AI), who had undergone a Le Fort I osteotomy, were analysed after a mean follow-up of 5 years. Two patients underwent a one-piece Le Fort I intrusion osteotomy and 13 patients a multi-segment Le Fort I osteotomy. In three of these patients, an additional bilateral sagittal split osteotomy was performed. Thirteen patients underwent a genioplasty. Surgery was followed by prosthetic rehabilitation in 10 patients. Skeletal and dento-alveolar stability were analysed on lateral cephalometric radiographs and condylar changes on orthopantomographic radiographs. Transverse stability of the dental arches was analysed on dental casts. The treatment results in this group were compared with patients with similar skeletal features but without amelogenesis imperfecta. The harmony of the long faces was restored and a reasonable vertical stability of the maxilla was achieved, however, a slight open bite and tongue interposition was still present. The transverse stability of dental arches (60%) was disappointing. Rigid internal fixation produced better transverse stability. Progressive condylar resorption was seen in two patients (13%). Less occlusal stability could be achieved in patients with AI, but resulted neither in less skeletal stability nor in more susceptibility to morphological condylar changes.

Treatment of the edentulous mandible with a vestibuloplasty combined with Intramobil Zylinder implants: a 5-year follow-up

The long-term success of endosseous implants is related to healthy peri-implant tissues. Attached keratinized mucosa does not seem important for the prevention of soft tissue complications. Prevention of muscle attachment near the implants, however, seems more decisive for maintaining a favourable peri-implant environment. We treated 150 patients from 1990-91 with two Intramobil Zylinder implants and modified vestibuloplasty, 65 of whom were randomly selected for evaluation at 1 year; 48 of the 65 were also seen at 5 years. The vestibuloplasty was done by the technique of Pichler and Trauner, to prevent muscle pull and to create a thin layer of mucosa around the implants, and endosseous osseointegrated implants were inserted. The results show an adequately depended vestibulum with no muscle pull around the implants and significantly lower pocket depth after 5 years of follow-up compared with similar studies.

Open bite deformity in amelogenesis imperfecta. Part 1: An analysis of contributory factors and implications for treatment

Anterior open bite (AOB) is often seen in patients with amelogenesis imperfecta (AI). The skeletal and dental components were analysed in 15 patients with AI and AOB. Measurements on cephalometric radiographs and dental models were compared with those of 130 patients with AOB but without enamel anomalies. Skeletal components in the AI and non-AI group were comparable. The AI group showed omega-shaped dental arches and a reversed mandibular curve of Spee. Orthodontic treatment options are limited because of the conical form of the teeth, tight contacts in the posterior regions and the condition of enamel resulting in difficulties in bonding brackets. Fixation problems encountered during surgery are discussed. A multidisciplinary treatment is outlined consisting of a multi-segment Le Fort I osteotomy followed by prosthetic rehabilitation to stabilize occlusion for at least one year postoperatively.

[Syndromes 2. Pfeiffer syndrome]

Acrocephalosyndactylias are syndromes characterized by abnormalities of the head (craniosynostosis), the face (hypertelorism, retromaxillism), hands and feet (cutaneous or bony syndactyly). Inheritance is autosomal dominant, but spontaneous cases are described also. The group is divided into several syndromes with varying penetrance and expressivity. As an example of an acrocephalosyndactylia is the Pfeiffer syndrome presented.

[Syndromes. 1. Cleidocranial dysplasia]

Dysostosis cleido-cranialis is mainly characterized by a pathognomonic deformity of the skull, a hypoplastic midface, lack of eruption of permanent teeth, supernumerary teeth, defects in the clavicles, short stature and multiple other skeletal deformities. The inheritance is autosomal dominant, but there is a considerable number of new mutations.

An image analysis study on nuclear morphology in metastasized and non-metastasized squamous cell carcinomas of the tongue

In a retrospective case-control study on 46 metastasized and 34 non-metastasized primary tongue carcinomas, the nuclear morphology and chromatin pattern were assessed in 3 microns thick, formalin-fixed, paraffin-embedded, and Feulgen-stained tissue sections of surgical resection specimens, by means of high-resolution computer-assisted image analysis. The aim of this study was to disclose differences in karyometric features, such as nuclear size-, shape-, and chromatin-pattern features, between these groups, with a view to developing a discriminant function that can predict the occurrence of metastasis for the individual patient. In addition, the lymph node metastases of 31 patients and the normal tongue epithelium of 21 patients were also assessed, to study the possible differences between these two groups and primary tumours. In the metastasized tumours, the chromatin was significantly more condensed (P = 0.01) and exhibited significantly less variation in chromatin condensation (P < 0.001) than in the group of non-metastasized carcinomas. Comparison of lymph node metastases with their primary tumours disclosed only minor differences in chromatin pattern. These findings suggest that only minor genetic differences exist between primary tongue carcinomas and their metastases. Tumour cells of tongue carcinomas showed highly significant differences from cells of normal tongue mucosa for most karyometric features. Logistic regression analysis resulted in a classifier, based on the circularity of the nucleus (CIRC) and the standard deviation of the chromatin condensation (SD COND), to predict the occurrence of lymph node metastases. After cross-validation, the percentages of correct classifications in the group of metastasized and non-metastasized tumours were 72 and 62 per cent, respectively. These results are comparable to the classification results obtained from a classifier based on the clinical T-stage, but our karyometric classification results show a much more equal distribution between the sensitivity and specificity. Karyometric features appeared to be more appropriate to predict metastases than biomarkers such as p53, bcl-2, and Ki-67.

Stability of transverse maxillary dental arch dimensions following orthodontic-surgical correction of anterior open bites

A sample of 130 patients with vertical maxillary hyperplasia; mandibular hypoplasia with a high mandibular plane angle; narrow, tapered maxillary dental arch form; and anterior vertical open bite were collected from three different institutions to evaluate the stability of transverse maxillary arch dimensions after correction of the open bite. Surgical treatment consisted of Le Fort I or bimaxillary osteotomies. Intermolar, interpremolar, and anterior arch widths were measured three-dimensionally on dental casts using a Reflex microscope, and transverse stability after orthodontic or surgical maxillary expansion was analyzed. Orthodontic expansion followed by a one-piece Le Fort I intrusion osteotomy was performed in 77 patients, and surgical maxillary expansion by a multisegment Le Fort I intrusion osteotomy was performed in 53 patients. The increase of transverse arch width and the relapse after orthodontic or surgical expansion were not significantly different. The transverse arch width in these two groups did not relapse in 20% of the patients after a mean follow-up of 69 months. An additional bilateral sagittal split osteotomy had no detectable effect on stability. Patients who underwent a multisegment Le Fort I osteotomy stabilized with rigid internal fixation showed better transverse stability than those with intraosseous wire fixation and maxillomandibular fixation. Maxillary intermolar and interpremolar arch width relapses were not correlated with tongue interposition or loss of interdigitation. The relapse of these arch widths showed significant correlations with clockwise rotation of the mandible but not with changes of overbite or overjet.

Randomized prospective clinical trial of two implant systems for overdenture treatment: a comparison of the 2-year and 5-year results using the clinical implant performance scale

In a prospective randomized clinical trial, edentulous patients were treated with dental implants and overdentures. The results of treatment with two IMZ implants connected by a Dolderbar, and a transmandibular implant (TMI) were compared. By using the clinical implant performance scale, the clinical and radiographic data were evaluated and compared after a two-year and five-year follow up. After the five-year follow up, significantly less problems and complications were recorded in the IMZ group than in the TMI group (Wilcoxon, P=0.03). When compared to the two-year follow up, there was, however, a gradual increase of scores on the clinical implant performance scale in the IMZ group, while in the TMI group only a slight increase was recorded.

Condylar remodelling and resorption after Le Fort I and bimaxillary osteotomies in patients with anterior open bite. A clinical and radiological study

A sample of 259 patients with vertical maxillary hyperplasia, mandibular hypoplasia and anterior vertical open bite, collected from three different institutions, was analysed regarding temporomandibular joint (TMJ) sounds, condylar remodelling, and condylar resorption. All patients underwent Le Fort I osteotomies, and bilateral sagittal split advancement osteotomies were performed in 117 patients. Intraosseous wire fixation was used in 149 and rigid internal fixation in 110 patients. Cephalometric and orthopantomographic radiographs were available before surgery, immediately after surgery, one year postoperatively and at the latest follow up. The mean follow up was 69 months (range 20-210 months). The number of patients with TMJ sounds decreased from 38% to 31%. At the latest follow up 23.6% of the patients showed condylar remodelling, 7.7% unilateral condylar resorption and 7.7% bilateral condylar resorption. Condylar contours, as assessed on orthopantomographic radiographs, were classified as five different types. Condyles with preexisting radiological signs of osteoarthrosis or having a posterior inclination were at high risk for progressive resorption. Female patients with severe anterior open bite, high mandibular plane angle and a low posterior-to-anterior facial height ratio, who underwent a bimaxillary osteotomy, were prone to condylar resorption. Bone loss was predominantly found at the anterior site of the condyle. The incidence of condylar resorption was significantly higher after bimaxillary osteotomies (23%) than after only Le Fort I intrusion osteotomies (9%). Avoidance of intermaxillary fixation by using rigid internal fixation tended to reduce condylar changes, in particular in patients who underwent only a Le Fort I osteotomy. Rigid internal fixation in bimaxillary osteotomies resulted in condylar remodelling in 30% and progressive condylar resorption in 19% of the patients. Condylar changes were not significantly different after using either miniplate osteosynthesis or positional screws in bilateral sagittal split osteotomy procedures.

Reproducibility of aimed-at profiles

Would a surgeon always draw the same aimed-at profile when planning the correction of a face with evidently malpositioned jaws? The same 10 profile lines were given to seven maxillofacial surgeons on two occasions at intervals of 6 months. The differences in absolute and proportional vertical measurements were compared. It is shown that the variations between first and second drawing were quite large for individual values. However, even the mean differences per measurement vary between surgeons from 0 to 10%. The drawings for the whole group corresponded reasonably well with the ratios given by Farkas and Munro (1987) but were rather divergent from the 'golden dimensions' proposed by Brons and Mulié (1993). Considering the sometimes significant differences, one is advised not to draw profiles 'off the cuff' but to use a construction system for planning osteotomies.

[Secondary posttraumatic correction of the face]

Any part of the face may present residual deviations in form and/or function after trauma, even if primary treatment has been executed optimally. Secondary corrections may be indicated as a consequence. The techniques are usually the same as for primary treatment. However since secondary corrections quite often are a consequence of complicated primary problems, it does not surprise, that frequently complex deformities present for secondary surgery. Depending on the nature of the lesion percentages of success between 60 and almost a 100% may be expected. This indicates that additional treatment after primary care may be a way out for quite a number of residual deformities.

Profiloplasty: variations in personal views

There is sometimes controversy among colleagues over treatment plans in orthognathic surgery. This is because there are differing ideas about which part of the facial skeleton should be moved to give an optimal result. A study was therefore set up to obtain insight into the differences between surgeons. Ten unbalanced profile drawings were given to seven experienced surgeons with the request that they draw the profile line which they would like to give these patients. It was acceptable either to draw the profiles 'artistically' off the cuff or to use additional construction lines as long as this was not the profile planning according to Brons and Mulié (1993). The evaluation showed that some surgeons drew profiles which resembled each other to some extent in proportions and inclinations, while others produced variations without any evident regularity and basic concept. The variability per profile was very important in almost all cases. Such discrepancies are not acceptable in a teaching centre.

Tooth eruption through autogenous and xenogenous bone transplants: a histological and radiographic evaluation in beagle dogs

The effect of implanting autogenous and xenogenous (Bio-Oss) bone transplants into metabolically active sites within beagle dog mandibles during permanent premolar tooth eruption was examined. Ten 14-week-old beagles were used. Before commencing the radiographic experiments, metal bone markers were placed in the caudal margin of the mandible at the age of 10 weeks. The deciduous first and third molar teeth were extracted and their sockets over the permanent second and fourth premolars were implanted with autogenous particulate enchondral iliac crest bone, autogenous particulate membraneous mandibular body bone, xenogenous bovine anorganic bone mineral spongiosa granules (1-2mm3) (Bio-Oss, Geistlich Pharma, Switzerland) of left empty. The third premolar served as control site. Standardized oblique lateral radiographs were taken once a week. A number of coordinates of defined points and structures were determined by means of a coordinate digitizing system. Animals were killed 4, 10 and 16 weeks after bone transplantation for histological examination of the transplantation sites. All premolars showed no delay in eruption or disruption of crown and root development. On histology, the Bio-Oss particles were not resorbed or integrated in the alveolar bone but were pushed forward into the gingiva. We have demonstrated that there is on difference in the eruption curve of the permanent premolars in the four groups (ANOVA P > 0.5) and that bone transplantation has no inhibitory effect on eruption (ANOVA P > 0.3) and crown development of the underlying permanent premolar but that Bio-Oss does not have the same resorbable or integrating capability as autogenous bone grafts.

Ectodermal dysplasia, cleft lip/palate, and severe cutaneous and osseous syndactyly in a mentally retarded girl: a new multiple malformation syndrome

A 13-year-old mentally retarded girl with severe cutaneous and osseous syndactyly of the hands and feet, cleft lip/palate, and ectodermal dysplasia is presented. We conclude that the pattern of malformations described represents a new multiple malformation syndrome. A comparison with Zlotogora-Ogür syndrome is presented.

Two-dimensional cephalometric analysis of the effects of subperiosteal palatal soft-tissue expansion in growing cats

The feasibility and possible effects of palatal soft-tissue expansion in palatal repair were studied. A prospective longitudinal animal experiment was performed in 75 growing cats assigned to 5 groups. In 31 cats, a midline defect was made, and bipediced flaps were raised at the age of 8 weeks (stimulated Langenbeck operation) in order to create palatal scars. At the age of 14 weeks, custom-made tissue expanders were inserted palatally in 61 animals. Tissue expansion was performed by weekly inflation in 33 cats (16 without and 17 with scars) for an 8-week period. The remaining 28 cats (14 without and 14 with scars) served as sham groups. A control group was formed by 14 animals (without scars and without tissue expanders). Soft-tissue gain and its effects on maxillofacial growth and development were measured in the midsagittal plane on tracings from standardized lateral radiographs. The effects of the experimental interventions were evaluated for 8 weeks after removal of the tissue expanders. Not all the cats yielded results at all time periods. This study showed that soft-tissue expansion of palatal mucoperiosteum is feasible. The surgically induced scars did not cause significant differences between the different groups in the midsagittal plane, and the data from both expansion and sham groups could be pooled. Significant soft-tissue gain was achieved by the tissue-expansion technique. Iatrogenic side effects were significant anteroposterior growth retardation at the level of the bony palate and an increase in vertical growth of the anterior nasomaxillary height and the posterior skull height during active tissue expansion. After removal of the tissue expanders, some accelerated growth was found in the tissue expansion in the scarred tissue group, with initial correction of the abnormal growth at the cranial base level. It is concluded that palatal soft-tissue expansion is possible in growing cats. This technique, however, impaired maxillofacial growth and development.

Skeletal and dento-alveolar stability of Le Fort I intrusion osteotomies and bimaxillary osteotomies in anterior open bite deformities. A retrospective three-centre study

A sample of 267 patients with maxillary hyperplasia, a Class I or Class II/I occlusion and anterior vertical open bites, collected from three different institutions, was analysed regarding stability after surgical corrections. Skeletal and dento-alveolar stability of the maxilla, and positional changes of the mandible and of the incisors were evaluated. All patients underwent Le Fort I intrusion osteotomies and in 92 patients segmentation of the maxillae was performed. An additional bilateral sagittal split advancement osteotomy was performed in 123 patients. Intraosseous wire fixation was used in 153 patients and rigid internal fixation in 114 patients. Cephalometric radiographs were collected before orthodontic treatment, before surgery, immediately after surgery, one year postoperatively and at the latest follow up. The mean follow up was 69 months (range 20-210 months). It can be concluded that patients with anterior open bites, treated with a Le Fort I osteotomy in one-piece or in multi-segments, with or without bilateral sagittal split osteotomy, exhibited good skeletal stability of the maxilla. Rigid internal fixation produced the best maxillary and mandibular stability. The mean overbite at the longest follow up was 1.24 mm and a lack of overlap between opposing incisors was present in 19%. The overbite did not differ significantly between the different treatment procedures, probably due to compensatory movements of the mandibular and maxillary incisors.

Osseointegrated oral implants in head and neck cancer patients

After cancer treatment in the head and neck area, mastication and speech are often affected. Some of the problems encountered can be solved by adequate dental rehabilitation. However, dental rehabilitation is often compromised for various reasons. The change in anatomy due to surgery often results in lack of denture-bearing mucosa. The effects of radiotherapy on the salivary glands and the mucosa result in dry oral tissue and diminished retention of removable dentures. Osseointegrated oral implants can help to solve these problems. Although implant treatment for patients with cancer of the head and neck is covered by the Dutch national health insurance, and there is therefore no financial obstacle, implants have not, so far, been widely used with these patients. In order to establish the possible reasons for this, an analysis was performed. Retrospective data on 95 consecutive patients were collected from records. The indication for the use of oral osseointegrated implants was reviewed. Analysis of the data showed that 45% did not need specific prosthetic rehabilitation. An indication for the use of osseointegrated implants was found in 25% of the patients. For various reasons, only 3% actually received implants. In striving to completely rehabilitate a cancer patient, the possible use of osseointegrated oral implants should be evaluated before the initial oncological treatment begins. The insertion of implants during the initial surgical procedure should be considered more often, with a view to reducing the number of surgical procedures.

Variations in the correction of Treacher Collins syndrome

A new combination of basically known techniques is described for the correction of Treacher Collins syndrome. The patients are treated in two to three operative sessions beginning early in the second decade of life. The main components are a chin advancement simultaneously with malar osteotomies in a first operation. In the second operation, the chin prominence is moved further forward by a simultaneous vertical movement of the maxilla, sagittal split osteotomy and body osteotomy of the mandible, together with a further chin advancement. Additional finishing touches may ask for a third intervention. Since there is a large variability of expression of the different signs, the techniques have to allow for a good deal of flexibility. The study of 10 patients reflects the considerable variations in the condition at the outset and the adequacy of the basic treatment protocol. The results of malar osteotomies are better than those of pure onlay augmentation. Despite the complexity of the maxillomandibular osteotomies, occlusal results are reasonably stable, and aesthetic improvement is considerable. The adaptation of the treatment to the individual patient resulted in modifications of direction of movement for different segments but also in omission of parts of the standard osteotomies. As a consequence, a modified treatment plan will be used as often as the standard program. The causes for the two not satisfying results are explained, and they demonstrate the limitations of the concept.

Improvement in oral function following tumour surgery by a combination of tongue plasty by the Steinhäuser technique and osseointegrated implants

Oral functions such as speaking, chewing and swallowing are often reduced after ablative tumour surgery in the mouth and oropharynx. For restoration of at least a part of these functions, stable dentures and satisfactory mobility of the tongue are necessary. Dental implants can be used to achieve stable dentures. Pre-implant surgery, however, is often needed to reduce the amount of bulky tissue when myocutaneous flaps have been used for reconstruction, and to achieve adequate mobility of the tongue. A combination of tongueplasty by the Steinhäuser technique and osseointegrated implants will be described and discussed. Twelve patients have been treated by this technique between 1992 and 1995, with a mean follow up of 11.6 months. All patients reported an improved tongue mobility and ability to chew. Tongueplasty by the Steinhäuser technique with secondary epithelialization, in combination with osseointegrated implants, is a simple and effective means of improving oral function.

Three-dimensional morphometric analysis of the effects of subperiosteal palatal soft-tissue expansion in growing cats

A prospective longitudinal study in 75 growing cats was conducted to evaluate palatal soft-tissue expansion in cleft lip and palate surgery. In 31 cats, palatal scars were induced by simulated Langenbeck surgery at the age of 8 weeks. At the age of 14 weeks, custom-made tissue expanders were inserted in 61 animals. Tissue expansion was performed by weekly inflation in 33 cats (16 without and 17 with scars) for an 8-week period. The remaining 28 cats (14 without and 14 with scars) served as sham groups. A control group was formed by 14 animals (without scars and without tissue expander). The effects of the experimental interventions were evaluated on a series of dental casts during the inflation period and until 8 weeks after removal of the tissue expander. The results indicate that soft-tissue expansion of the palatal mucoperiosteum is feasible. Until 20 weeks of age, no differences were found between both expansion and sham groups. Thereafter, significant soft-tissue surface-area gain was quantified in relation to the base surface and base diameter of the tissue expander. Iatrogenic side-effects of active tissue expansion consisted of significant transversal growth retardation in the anterior part of the bony palate and dentoalveolar structures. After removal of the tissue expanders, some accelerated growth in the tissue-expansion, scarred-tissue group was seen. It is concluded that palatal soft-tissue expansion is possible in growing cats, with and without the presence of palatal scars; however, this technique, like other kinds of palatal surgery, impairs dentomaxillary growth and development.

Transmandibular implant versus intramobile cylinder implants: a randomized, prospective clinical trial

A randomized, controlled clinical trial was conducted to compare two different implant treatment modalities for edentulous patients with severely resorbed mandibles. In one modality (the IMZ group), two intramobile cylinder implants were placed, connected by a Dolder bar and provided with an overdenture, and in the other (the TMI group), a transmandibular implant with a triple bar and cantilever extensions was placed, likewise provided with an overdenture. The conditions of the overdentures, the peri-implant tissues, and the implants were evaluated. Orthopantomograms were taken for radiologic evaluation. An overall complication scale which took account of all aspects was devised to compare the results. The follow-up period was 2-4 years, with a mean follow-up of 3 years. The condition of dentures and oral hygiene aspects were comparable for both groups. The complication rate in the TMI group was significantly higher than that in the IMZ group. The scores on the complication scale resulted in a significant difference between the TMI and the IMZ groups (Wilcoxon, P = 0.0044).

Supraperiosteal flap technique versus mucoperiosteal flap technique in cleft palate surgery

Recent animal experiments have shown that palatal repair without denudation of bone leads to a superior dento-alveolar development. The aim of this clinical study was to evaluate the peri- and postoperative course and the dento-alveolar development of the deciduous dentition in Japanese ULCP, and CP patients up to 5 years after two different types of palatal repair. One of the methods, the Kohama (1991) supraperiosteal flap technique, is performed without denudation of the bony palate, while the other, the Wardill (1937) push-back technique, results in areas of denuded bone. It was concluded that the supraperiosteal technique can be performed successfully in approximately the same amount of time as the push-back technique. Re-epithelialization of the wound areas after supraperiosteal repair takes about 1 week, which is one third of the time associated with healing after the push-back technique. Arch depth of the deciduous dentition after the supraperiosteal technique is superior compared to the push-back technique. The question of whether or not the supraperiosteal technique produces more favorable dento-alveolar development than the mucoperiosteal technique in the permanent dentition in humans has to be elucidated in future research.

Neurofibroma in the articular disc of the temporomandibular joint: a case report

In classical Von Recklinghausen neurofibromatosis (Type I), skeletal defects occur as a result of abnormalities of derivatives of the neuroectoderm and mesoderm. Temporomandibular joint (TMJ) disorders caused by neurofibroma in the joint capsule or disc have not been reported previously in the English language literature. A case of neurofibroma in the TMJ articular disc in a 29-year-old woman with neurofibromatosis Type I is presented.

Palatal mucoperiosteal expansion as an adjunct to palatal fistula repair: case report and review of the literature

Case report of conventional palatal soft-tissue expansion in an attempt at cleft palate fistula closure with a standard tissue expander. This technique may be an alternative to a tongue flap to promote closure of persistent oronasal fistula.

[Skull roof reconstruction in infants]

In this article an introduction into craniofacial surgery in children is given based on the case histories of two patients (cleido-cranial dysplasia and cranio-synostosis).

Occlusal and functional conditions after surgical correction of anterior open bite deformities

The dental occlusion and alterations in orofacial muscles were studied in 267 patients whose severe anterior open bite had been treated with a Le Fort 1 intrusion osteotomy with or without an advancement sagittal split osteotomy about 6 years ago. Only 17% of those patients showed anterior contact, and 20% had no vertical overlap of mandibular and maxillary central incisors at all. Tongue position, activity of masticatory muscles, lip competence, lip-incisor relationship, and breathing mode were assessed. Statistically significant correlations were found between tongue positions and occlusion in both the anterior and the posterior regions. In addition, the activity of the masticatory muscles, habitual mouth posture, and interlabial distance were each significantly correlated to overbite, open bite, and overjet. The interlabial distance was also significantly correlated with both breathing mode and mentalis muscle activity. The activity of the masticatory muscles was negatively correlated with tongue position.

Palatal surgery without denudation of bone favours dentoalveolar development in dogs

The present study compared the dentoalveolar development in beagle dogs after palatal repair according to the partially split flap technique and the von Langenbeck method. It was concluded that palatal surgery according to the partially split flap technique resulted in significantly wider transverse distances of the maxillary dental arch than after the von Langenbeck procedure and that its final outcome closely resembled that of the control group.

Effectiveness of primary correction of traumatic telecanthus

To assess the aesthetic and functional results of primary treatment of telecanthus in patients with naso-orbito-ethmoidal fractures, the results in 36 patients were evaluated in a retrospective study. Twenty had double-sided telecanthus: 13 required an indirect technique of canthopexy and seven a direct technique. Sixteen had unilateral telecanthus, of whom six were treated by the indirect and 10 by the direct technique. The intercanthal distance (ICD) was measured directly postoperatively and more than 12 months after reconstruction. The late ICD after application of the direct technique was nearly 3 mm smaller (ANOVA, P < or = 0.02, mean 34.3 mm) and yielded 2 mm less relapse (ANOVA, P < or = 0.02) as compared with the indirect technique. Delayed or late-primary treatment showed a significantly higher frequency of epiphora (chi-square test, P < or = 0.05). Early primary treatment of traumatic telecanthus produced the best aesthetic and functional result.

Reversing segmental osteotomies of the upper jaw

Three patients are presented in whom retropositioning of the anterior upper teeth resulted in accelerated aging of the face. Two basically different approaches to correct these bad results are illustrated. It is shown that onlaying of the maxillary base is insufficient but can be the only solution possible. Reversing the primary procedure seems much more effective. The technique, however, can be very demanding.

Effectiveness of secondary post-traumatic periorbital reconstruction

In a 12-year period, 56 consecutive patients have undergone secondary periorbital reconstruction after trauma. To evaluate the overall results and the need for further correction, three diagnostic groups were formed. These were: malar bone (n = 16), midface (n = 16) and fronto-orbital fractures (n = 24). Also, in order to judge the reliability of the procedures used most frequently, all osteotomies of the zygoma (n = 32 in 30 patients), canthopexies (n = 26 in 19 patients) and corrections of the bony nasal skeleton (n = 26) were assessed as separate groups. After malar fractures, poor results were found in two cases while after midface fractures the results were quite satisfactory with only one poor result. The outcome after fronto-orbital fractures was also generally satisfactory. However, after a considerable number of later corrections there were still four poor results. Unfortunately, osteotomy of the zygoma left a rather high percentage of unsatisfactory results (19%), but canthopexies scored high and further corrections after secondary surgery of the nasal skeleton eliminated all but one poor result. It is concluded that 7% of our trauma patients undergo secondary and further periorbital corrections. The techniques have become routine. The final outcome was assessed as good in 60% and poor in 20% of patients.

Fracture of costochondral graft in temporomandibular joint reconstructive surgery: an unexpected complication

The case of a 35-year-old woman with a history of several temporomandibular joint (TMJ) operations, including condylectomy, is reported. She presented with myofacial pain and partial fibrous ankylosis of her right TMJ. The ankylosis was released and an autogenous costochondral graft was used to restore the vertical dimension of the ramus. About 3 months after surgery, a fracture of the graft occurred during physical therapy. The cause of this complication is discussed with reference to the literature.

[Is segmental osteotomy of the jaws outdated?]

In earlier days segmental osteotomies had a broad field of indications. In the era of combined surgical-orthodontic treatments, they are pushed far into the background. This article shows that this development is unjust. If carefully indicated, segmental osteotomies still have a well-defined place in our armory of surgical interventions. With their elegance and the compulsion to respect detail they are not only of marked didactic value, but they also fill a gap, especially in the treatment options for the lower jaw. Far from being obsolete, they should still belong to the routine options when orthognathic surgery is considered.

Radiologic analysis of the effects of subperiosteal palatal soft-tissue expansion in growing cats

Palatal soft-tissue expansion might be appropriate for use in cleft palate surgery. Seventy-five cats were divided into four different experimental groups and one control group. Intraoral tissue expansion was started at the age of 14 weeks in normal or scarred mucoperiosteum. The experiment lasted until 24 weeks of age. Serial standardized lateral cephalograms from each animal were digitized, and the results were statistically analyzed. The results indicate that the effects are independent of the presence of scarred tissue, that sagittal growth is impaired by tissue expansion, and that the tissue expander induced resorption of palatal bone.

Autogenous transplantation of third molars in irradiated jaws--a preliminary report

Our experience with third molar autotransplants in 2 patients, into an area irradiated at an early age, is described and discussed. It is shown that such autotransplantations are possible.